Up in the elevator I go for PCS #3 on the cardiac floor. My CE was just as I had expected, so sweet, chatting about the beautiful sunshine. Oriented to the floor, she slips out some things about my patient as she's showing me the oxygen in the rooms so I instantly knew I had Impaired Gas Exchange before she even handed me the Kardex. If I learned anything from the day before it was to take any hint or info and jump ahead wherever possible, those minutes are precious (just like writing on my alcohol swab!). And then I get my patient info, sure enough CHF, COPD, admitted with severe dyspnea, on 02, with oxygen management assigned... Impaired Gas Exchange is a GO! I had a peripheral vascular assessment, 5 meds including another Lovenox, flush IVAD, OOB to chair, patient teaching on fluid management, and I & O. I knew my second diagnosis would be Activity Intolerance (3 for 3 folks) and care plan was a piece of cake.
Patient was wonderful, did my 20 minute check quickly since I only had to check hydration. Explained the I & O ordeal, went to get vitals and the BP cuff was acting odd but finally worked. Her BP was quite low 109/36... I did my PVA and told her we were going to help her get out to her chair after I brought her meds in which she was happy to do. Got meds, did the whole check off thing. Meds here came as ready-dose individually packaged with barcodes, so you scan and tear them open one at a time. Almost fooled myself with the Prozac dose as I went down the list, 40 mg ordered, only had 20 mg pill... then realized after a small panic that there were 2 tabs separately packaged. The little things can stress you out unnecessarily, gotta keep breathing and regroup.
I mentioned something about no allergies and no special assessments for the meds (ie. Dig with an apical pulse) and she said "well her BP is kind of low" and I stopped and thought for a minute. First I wasn't too confident in the reading that the machine gave since the cuff wasn't acting right. Second there were no special orders to hold any meds for a specific reason. I knew I was giving Lasix and Amlodopine and it could cause an issue but she also had received an 0800 BP med as well so this may just be the "normal" for her.... I didn't want her bottoming out though as I went to put her in the chair so I told the CE all of this and said I wanted to get my drug book and pull up her chart before signing off on my meds to give and that I'd also recheck the BP when we went in. No info really in the drug book about parameters, it's all docs call. Chart showed that her BP did tend to fall around that 110/50 ish... CE and I both talked it over a little and mutually decided to get the primary and see what she wanted us to do. We opted to go in and give her the rest of her meds and her subq and then come back for the other 2. This was fine but meant making sure you did those 5 rights and med checks precisely TWO times instead of one. Did my Lovenox, remembered the 2x2 this time :) Finally talked to the primary who said go for it, so I went in and almost started to open the packages for the remaining 2 meds and remembered I hadn't rechecked the BP. Just as I remembered the CE also spoke up and said "oh you want that BP right?" Had I forgotten she was trying to help me out, such a nice lady. So I stopped, new BP 127/49, better so I wrote it down. Threw in some interventions while I was giving her meds about moving slow, taking time, using devices if needed etc. Then it was up to her chair and I remembered that I needed to flush her IV. So I told her I'd be back to do that shortly and then I'd be out of her hair. Flush was 3mL so I had to squirt out the excess in the syringe, no bubbles, etc JUST like in the lab. Have to verify the dose and everything. Assessed and flushed site, wrote down my remaining intake totals, had to measure a cup of water precisely (the other CE's didn't care if it was that accurate but she did, so I measured). Headed out to chart and reminded myself to stay focused, I was AL. MOST. there.
Had plenty of time, wrote my narratives, included an "other" note about the BP ordeal, did the evaluation, re-read everything. Declared my vitals and said I was done and off she went. I felt really good about this one, the patient was super easy, the care plan was flawless, I hit every intervention on the nose, I did it! And all of a sudden my heart sunk because I couldn't remember for the LIFE of me if I checked the box "met" on my evaluation form. I couldn't remember.... So once again, that old familiar extreme panic and heart palpitations...
She came back down the hall about
I saw the wonderful CA Lynda poke her head out and call me over, she walked me into the conference room and said congratulations opened the door where the CE's were all sitting and said "We have a GRADUATE NURSE!!!!" and they all cheered and clapped and I started crying again thanking them all for being a part of this crazy journey. She handed me my letter. That letter I'd been picturing for SO long. And the book... from orientation... where I sat down and offered my best wisdom and encouragement to those coming up to test next....
"Just 2 days ago I was handed this very book as I awaited the lab check offs with a pit in my stomach.... and here I sit ready to walk out those hospital doors with my pass letter just as I had envisioned for so long....(....) KNOCK EM' DEAD"
~A.F. Graduate Nurse omg